HomeMy WebLinkAbout024-641-24-4101-SAN-2022-294 "'� Department of Safety c01"ry (/�
. �U ' � �
�s' : & Professional Services, Sanitary Permit Number(to be filled in by Cc �
t Industry Services Division
� Cp 3 q �-�S �
Sanitary Permit Application State Transaction Number �
,
[n accordance with SPS 383.21(2),Wis Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing ad� .�
the Department of Safery and Professional Services.Personal information you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. 1�.04(I)(m),Stats. 7 j�W �I UC �` �'L1C
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�-'v� �C�S� �+ D�.��n�t �J. Sfe���] U 2�.f-- (c�� -2-� - �IO/
Property Owner's Mailing Address Property Location
'f Zb'� �C�.e,'���� �i,i^��.E'
City,State Zip Code Phone Number u
�(.l' �(i'1 �/l /l�� 5 .S�Z- 3 4�5� -2�7�{- (G��t Cl! �'/,. s� 'h. Section Z 7
II.Type of Building(check all that apply) � Lot# � T �' N R W
I or 2 Family Dwellin�-Number ofBedrooms
Subdivision Name
Block#
❑Public/Commercial-Describe Use
�City of
❑State Owned-Describe Use CSM Number ❑Village of
���,3 � �,�5� �rown of `i�+l� 11�1� _
III.Type of PO�VTS Permit:(Check either"New"or"Reptacement"and other applicable on line A. Check one boz on line B.Complete line C if
a licable.
A.
❑ New System �Replacement System ❑ Other Moditication to Existing System(explain) ❑Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Revision ❑ Chan e of Plumber ist Previous Permit Number and Date Issued
❑ Renewal Before g ❑ Transfer to New Owner
Expirahon
kh , 7
IV.Dispersal/Treatment Area and Tank Information:
Design Plow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �T Q =
�OG' . 7 £s'.5� ��7S c= k� D=�7 S � =S1s ;cs
Capaciry in Total #of ManuYacturer
Tank[nformation Gallons Gallons Units � ` � y �
New�I'anks Existing Tanks 'L � y ` L � � �
` c � �
c. U �n � rr� i:, U a
Septic in "Cank ��ZS�� �Z�'} � ��£ �
�f�
Dosing Chambzr
V.Responsibility Statement- [,the undersigned,assume responsib' for insta ation of the PO�VTS shown on the attached plans.
Plumber's Name(Print) Plumber's re + ,,,.,� NIP/N{�I�S Number Business Phone Number�
,/ �.�'-r, .,
a SG7'l
Kidf � � <.s�:",...;.;�.:>�i �?S ?�-( �lS- �7C�''�JJS
Plumber's Ad ress(Street,City,State,Zip Code
� p � ��,C,�; C�C� ��(,� ��� .5�:�L�
VI.County/Department Use Only
�App �� Disapproved Permit Fee Date[ssued [ssuin�Aaent Signa[ure
�L✓ ❑Owner Given Reason for Dtnial � t w•� �C I�� I oZ� ��"�t/u.C-e�c...7�r^'�`^'y
Conditions of ApprovaVReasons for Disapproval , �l'� ���r;.��'�'
�r3�C�_ �C I (� 1��_ .. _. t�I�����Jr � � _ "i
'��' � �, r�
G �r�,�
I�
r�'�►C �3�aS
�..h�" _ _.___._____.. _._ n� � ��� � 6 2Q22 � �l
�.
^ ¢� o�_Y_____. ._ =i-- ._—_..i'
C S 1 �-�-- �p�j �" ' � `l,l.e.�r.�..�_ ��► �-3 8�(5 ,-„
SAWYER C'vz;��,� �
�+ ZONING ADM(f�►i;;�i�tiT;Ctv
Attach to complete plans for the system and submit to the Counh'only on paper not less than S I/?x 11 inches in size �� I f�
J
NO RiFJNDS AFTER
SBD-639S(R.03/22) IS3UE OF PC:FMI'I'
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index&Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section &Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s):7eares�c�T ` �C�cutc�J. Sfe{�e�� Phone: �51 _Z�`f _ vl4'f
Owner Address: 4 z1�� ���5� ' C���� Fti �zr� nP� Zip: SSr 2 3
Project Address: 7�'zfW Z3�ut 7�tY ���c ��cci2����c'T-
Gev�k�t:��E NE 1/4of s� 1/4,Section 2`f ,T `fl N-R � E❑or W�
Township: ���� �-�-(<� County: ��Gti��-Iz('
Project Parcel ID#: �72�f-Ca�F(—Z�F- `f/�/
Designer Information
Designer Name: Jci��� {�u��e� Phone: ?/5 - 7�f�- �}S5�
DesignerAddress: � � � �� CLc�(ti��� Zip: S`f��-/
E-mai1: 1(�'n'�'Cc�idv+-ir�s.�'"'�'
License Number: 10�5�7��
Remarks:
Signature: �����_�� f� Date: io�s/z
Original signaWr re uired on each submitled copy.
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PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code,this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shail be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disqersal Area Operatinq Limits:
Design Flow= �P� gpd; BODS<_220 mgL''; TSS 5 150 mgL''; FOG<_30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatment tank(s)and any distribution appurtenance(s)(i.e.,distribution/drop boxes)
o negiect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Septic and dose tank(s)shall be pumped by a ceRified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent filter(sl shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: �-},I�.lsvYb(,t��-� � Jb✓l S Phone:�7�S� �4�' >;S�
Local government uniY. `�.(,v�lto''�� ����ti'��it Phone:(�lJ�(a��/'�z��
Localgovernmentunitaddress: ��,'�(()Qp��X� ��-�� ZIP: �{�� _
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wlsc.Admin.Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shall be replaced oursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
��"�^0.T1f" PRIVATE ONSITE WAS�E TREATMENT county
-�,,,;
� > �' SYSTEMS Sawyer
i�� �gPs\i��
'`��� �_ij ( POWTS)
�h�`„_,��
"—°�'='' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.� _ ��'�f'
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 1�.04(1)(m)J �
Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
1 eS¢.�1C2.�'�Nv►c� �,c'�v�•� L.a�(¢,� �-
Insp BM Etev: BM Description: Parcei Tax No:
l O 0.(�' I�P�1� t ��-�� � 1�-.-- b��{-6Y�-.� - �!I� I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic t,�.��-- � a� Benchmark �po,��
Dosing
Aeration Bldg. Sewer �t�o.o'
Holding St/Ht Inlet �j s �
TANK SETBACK INFORMATION St I Ht outlet �
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet ,
AIR INTAKE
Septic .��.�' � t d-ib` .�o` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q� $s- r
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Surf cte e�'�6 R I,o �
Manufacturer Demand Final Gratle
Model Number GPM g . �- $9.0 �
TDH Lift Friction Loss Sys Head TDH Ft S S, � ���5'
Forcemain L Dia Dist. To Well � �$;2S '
DISPERSAL CELL INFOR ATION
DIMENSIONS �N 3� L S r 3s' ' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
P/L Bldg Well o IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO k �o` a� �` ,}-�' ❑ Mound o Other
-- —-- - - - __ - —--- --- — --
DISTRIBUTION SYSTEM X Pressure Systems only
— ___. _.
Header/Manifoltl Distribution Pipe(s) � X Hole Size X Hole Observation Pipes
( Length Dia � Length Dia Spac j Spacing ❑Yes ❑ No
- -- - -- - ---------
SOIL COVER
� Depth Over Depth Over Depth of —_- � Seeded/Sodded � Mulched �
Cell Center Cell Edges � Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��s�►I(� ��la�'�2�
Plan revision required?0 Yes❑ No p3 to 0l3 � • I�v � � ��� �
.E:��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADDITIONAL C�MMENTS ANO SKETCH
SANITAAY PERMIT NUMBER: � �-z9"�
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